Ms. Smith is a 32-year-old biracial, female, who has completed high school and is currently employed as a waitress. Ms. Smith was taken to the hospital on 3/18/2019 by local police, who found her screaming, pacing, and weeping inconsolably outside of a local apartment building on 5th Street. Apartment residents called police to the scene, concerned by the disturbance Ms. Smith was creating.
Captain Logan, with Fire and Rescue, arrived second on the scene and treated Ms. Smith for multiple cuts on her arms. Exhausted by apparent despair, Ms. Smith conveyed she moved to town one month earlier from Memphis, TN, looking for a new start. She met her boyfriend, Frank, six days after starting her new job, and they have gone out six times. According to Ms. Smith, “Frank is my destiny, he has to love me as much as I love him!” Officers at the scene learn that Frank, hours earlier, told Ms. Smith he never wanted to see her again and that Ms. Smith has a restraining order against her in San Diego, CA.
Ms. Smith has been referred to Dr. Liam for psychological evaluation due to immediate concerns for risk of self-harm.
Currently, Ms. Smith, reports that her head sometimes feels numb and that her thoughts are confused. She is experiencing incredibly strong feelings of fear, seeing herself as being abandoned and alone in a strange new town. She self identifies as a passionate woman capable of foolish things that she is sometimes sorry for, to include unprotected sex with multiple partners before meeting Frank.
When interviewed by police the day Ms. Smith was escorted from his apartment complex, Frank reported that Ms. Smith’s behaviors toward him rapidly became impulsive and demanding after their first date. At first Ms. Smith was charming and thoughtful. She would surprise him with small, simple gifts (e.g., movie tickets). She then started to send affectionate text messages every half hour. The nature of the text messages quickly shifted from casual and flirty to strong expressions of passion and love sent every 10 minutes. When Frank did not respond to these messages, in frequency or kind, Ms. Smith would suddenly ignore him or lash out.
When asked about this behavior, Ms. Smith reported she regretted her negative actions towards Frank immediately after she did them, experiencing regret or panic after lashing out. Having been in many relationships before, that according to her, ‘did not work out,’ Ms. Smith could not stand the idea of Frank, her perfect love, seeing her as unkind.
Now that Frank has broken up with Ms. Smith, she feels empty, powerless, and worthless. She attributes this sorrow as the reasons behind her sudden mood swings. Her thoughts and emotions stray between extreme agitation and a compulsion to act out to apathy and a desire to withdraw.
Ms. Smith’s mother, Helen Taylor, and father, Jake Smith, were both heroin addicts. Her mother claims she did not use drugs while pregnant with Ms. Smith, attributing the life-style change to having completed rehabilitation two months prior to becoming pregnant. During the pregnancy, Ms. Taylor did not seek prenatal care due to a fear of doctors and a lack of financial security. At delivery, Ms. Smith reports she thinks she was a normal, healthy infant.
Ms. Smith reports that her mother, Ms. Taylor, was not interested in being a mother and abandoned her to the care of Mr. Smith when she was 8-months old, upon his release from jail, following incarceration for stealing a wedding band to wed Ms. Taylor.
Growing up, Ms. Smith had two older half-brothers, and one younger half-sister. Her mother had multiple relationships prior to meeting Mr. Smith and is the mother of Ms. Smith’s brothers. Ms. Smith’s half-sister is the child of her father and stepmother. Ms. Smith lived with her father and stepmother until she was 18 years-of-age. The years between 2 and 8 she describes as the most influential. She struggled with confusion as to why her mother did not want her and why her stepmother ignored her. She also suffered malnutrition due to lacking food in the home.
Between the ages of 7 and 17, Ms. Smith continued to lack food and emotional security. She also withdrew into bouts of self-loathing and wishing for a permanent out for her mental, emotional, and physical suffering. Her father’s moods were unpredictable, and her stepmother hit her frequently. Ms. Smith reports that no longer what she did (skipped school, brought home straight A’s), her stepmother expressed upset towards her. Owning one pair of jeans, four shirts and one pair of shoes by the time she turned 18, Ms. Smith was sensitive to the judgement of others. In middle school and high school, she was overly self-focused and overreacted if she sensed a hint of judgement or rejection from others. This reactance often led to sudden moments of violence (fights, throwing objects, verbal assaults) against those Ms. Smith felt wronged by. During this period, Ms. Smith also took up the use of alcohol to counter regrets for her negativity towards others, and the wallowing emotional pit of nothingness she sometimes found herself in.
Ms. Smith did disclose a family history of mental health challenges and anger management issues, though most she attributes to illegal substance use difficulties. Ms. Smith says she has worked with multiple therapists over the years but has not had luck finding one who understands her enough to bring about change. Reportedly, Ms. Smith was not athletic as a child or teen, but was good at art, music, and writing. She participated in band until her stepmother made it impossible for her to make it to band practice on time, making her miss the morning school bus.
Pointed to above, Ms. Smith’s relationships with others have, and continue to be brief, beginning with idealization of a person and then a rapid period of denigration and demands of that person.
Ms. Smith explained that she was an early reader and began to read while attending a Jump Start Program. Ms. Smith stated that, during the first grade, she “loved” her teacher Mr. V., but he never paid attention to her. Ms. Smith reported that she performed quite well academically from the second through the fifth grade. This period marks a time before a move across country to a new town. In sixth grade, Ms. Smith changed schools. The middle school and high school years marked a period where her teachers knew her homelife was poor and they worked to get her into advanced classes. Currently, Ms. Smith is working as a waitress, but aspires to enter the music industry as a song writer. She has always been talented with the written word, according to her. This career focus will be her fourth “remaking of herself” in the past 18 months.
Alcohol Substance Abuse:
Ms. Smith denied use of any illegal drugs or any prescription drugs, but does overindulge in alcohol.
Conduct and Legal:
Reportedly, Ms. Smith has a restraining order against her in the state of California. The order is to maintain over 100 feet from a past romantic interest. Ms. Smith acknowledge she was disappointed her affection was perceived as overly demanding and blames the failure of the relationship on the fact the person was married.
Ms. Smith is a 32-year-old, biracial female of average height and petite frame. She appeared her stated age, arrived at the evaluation agitated and dressed in clothes that may have been slept in. She was polite and cooperative at one moment and then sarcastic or argumentative the next during the evaluation. Ms. Smith is left-handed. When challenged she would response with explosive anger, then retrack with an apology and body language that expressed guilt or remorse. Attention and concentration were slightly impaired. Ms. Smith’s thought processes were connected, while logic applied to decision making was not always coherent. Ms. Smith’s eye contact during the evaluation was dependent on her mood.
Regarding her motor functioning, there are no apparent abnormalities. No evidence of impaired vision or hearing was present during this evaluation. Ms. Smith did not demonstrate any difficulties with speech and appeared to demonstrate the ability to both understand and express the English language without notable exceptions. The content of her thought was occasionally tangential, moving off topic to the discussion of Frank, or to make personal inquiries directed at getting to know Dr. Liam. Her preoccupation with being abandoned does not appear to reflect paranoid thinking. Her affect shifts rapid, contingent on topic of the discussion. She did not report hallucinations or delusions. Ms. Smith’s gait and pace reflected shifts in mood throughout the session. She did express suicidal but not homicidal ideation.
STEP 2: Draft a Case Conceptualization
Apply cumulative knowledge from this course and others (i.e., abnormal psychology) to diagnosis Ms. Smith, support your diagnosis with evidence from the case and recommend further assessment and treatment options. Your paper should consist of the following sections:
Part I: Reason for Referral
- What was the reason for the referral?
- What sources of data do you have and need?
Part II: Background Summary
- Family/Social, (supports) Include ethnic/racial/cultural
- Medical/ developmental
- Educational/occupational (hobbies)
- Behavioral observations
Part III: Assessment Data
1.In addition to a good diagnostic interview, what assessment tools would you recommend using to aid in giving an accurate diagnosis and developing a treatment plan?
Part IV: Tentative Diagnosis
- Select a diagnosis using the DSM-5
- Defend which diagnosis/diagnoses are possible using specific examples from the case.
Part V: Treatment Recommendations
- Consider which treatment would be the ethical choice (community, group, referral to a forensic psychologist, psychiatrist, physician or for a neuropsychology evaluation).
- Provide one or two Evidence Based Treatment recommendation for the diagnosis given. Be sure to cite the source that helped you to determine the best Evidence Based Treatment for this diagnosis.
Part VI: Considerations
Clearly present your analysis of developmental, sociocultural, and ethical considerations that contribute to the diagnosis and treatment recommendations made.
- Developmental Considerations
- Sociocultural Considerations
- Ethical Considerations
Part VII: Conclusion
- Conclude with a summary of your findings.